Why do we die?

[name?]

Hi all,


I've got a bit a strange question that I'm having trouble with lately. What are people dying of now? I see 80+ year olds with chest pain daily that get ruled out and sent home, or get cathed and stented, my demented 90 year olds from their homes with UTIs that get treated and sent home to keep shuffling along. So, as I see it, there are still the typical bad things--trauma, lethal arrhytmia after MI, GI bleeds, sequela of self-abusive behavior etc that lead to ED-type deaths, but who's dying at home?

I've given morphine to a DNR 80+ year old that was comfort measures only and it was one of the more heroic feelings I've had doing this--I got to make her last moments pain free and peaceful--I sort of felt like I was the doctor I envisioned myself being.

But, all too often, it's admitting or CTing the demented fall, antibiotics for the infirm with yet another UTI/PNA. I even had to admit an 85 year old on their 3rd round of chemo last week--with neutropenia and local zoster and pyelo. Why the hell is any 85 year old on chemo for anything? I feel like our culture is so afraid of death that we make it as ugly and fearful as possible instead of giving people reassurance that we'll make their remaining time pain free. It's driving me nuts.

Plus, from the political/economic front, it seems like we could probably save an absolutely insane amount of money if we did have some lines drawn about when it was reasonable to keep treating and when was reasonable and honorable to stop without facing angry family members and the treat of litigation. As my parents start to head into the elderly demographic I still feel like we shouldn't throw every resource at them just because we love them and we can.

Why can't we let people die as a medical culture? Last time I checked, it's still 100% mortality on this planet, and yet for each person it's its own painful struggle when the quality/quantity equation is so clearly in favor of quantity. This is especially baffling to me as the country tends to be more religious (certainly more religious than my heathen self) and yet even with the promise of an afterlife we can't let people go.

I'd love to hear your thoughts/experiences with things like this. It seems like an area where we in the ED are the unlikely proponents for quality end of life care, and an area where if we as a society could gain some more global acceptance, we could save money and take better care of people.

Sorry for the lengthy post.


Sorry wrong title..more like why don't we let people die well?

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[SeekerOfTheTree]

It's hard to let go.

 

[leorl]

It's a good question and one that comes up in the ED on a near-daily basis. There are people starting to explore this now with ED physicians doing pain/palliative fellowships and developing relationships with hospice facilities. A couple months ago with the help of a care coordinator and as per family / proxy wishes, I sent a completely septic (hx repeated frequent bouts of sepsis and other debilitating conditions) very elderly person home (the hospice) with no antibiotics and only some IV fluids. The whole family had gathered and they seemed very happy and at peace that this was ultimately the right decision. And I also had that satisfied feeling of doing the right thing for thing for that patient/family/medical expenditure.

I thought it was really insightful of that family to have decided that because it happens more often than not that a non-communicative demented patient with a poor prognosis that you've spent hours of "critical care time" on goes to MICU only to be made DNR soon after transfer and ending life in the hospital, when it could occur in a more comfortable and peaceful setting.

The only problem is once you put legal restrictions on things like this, people are bound to be very upset. What if someone who is a very spry and with it 90 yr old suddenly falls seriously ill and legal restrictions limit the kind of care that can be given? It would be hard to not have difficulty letting go and not providing a more aggessive form of care in that instance (depending on the condition and the general prognosis of that condition). And it would be hard legally deciding where the line should be drawn.

But defo a hot topic right now. We see things differently than the general population a lot of times. Just in case you haven't seen this: http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/

 

[Hamhock]

Hi all,


I've got a bit a strange question that I'm having trouble with lately. What are people dying of now? I see 80+ year olds with chest pain daily that get ruled out and sent home, or get cathed and stented, my demented 90 year olds from their homes with UTIs that get treated and sent home to keep shuffling along. So, as I see it, there are still the typical bad things--trauma, lethal arrhytmia after MI, GI bleeds, sequela of self-abusive behavior etc that lead to ED-type deaths, but who's dying at home?

I've given morphine to a DNR 80+ year old that was comfort measures only and it was one of the more heroic feelings I've had doing this--I got to make her last moments pain free and peaceful--I sort of felt like I was the doctor I envisioned myself being.

But, all too often, it's admitting or CTing the demented fall, antibiotics for the infirm with yet another UTI/PNA. I even had to admit an 85 year old on their 3rd round of chemo last week--with neutropenia and local zoster and pyelo. Why the hell is any 85 year old on chemo for anything? I feel like our culture is so afraid of death that we make it as ugly and fearful as possible instead of giving people reassurance that we'll make their remaining time pain free. It's driving me nuts.

Plus, from the political/economic front, it seems like we could probably save an absolutely insane amount of money if we did have some lines drawn about when it was reasonable to keep treating and when was reasonable and honorable to stop without facing angry family members and the treat of litigation. As my parents start to head into the elderly demographic I still feel like we shouldn't throw every resource at them just because we love them and we can.

Why can't we let people die as a medical culture? Last time I checked, it's still 100% mortality on this planet, and yet for each person it's its own painful struggle when the quality/quantity equation is so clearly in favor of quantity. This is especially baffling to me as the country tends to be more religious (certainly more religious than my heathen self) and yet even with the promise of an afterlife we can't let people go.

I'd love to hear your thoughts/experiences with things like this. It seems like an area where we in the ED are the unlikely proponents for quality end of life care, and an area where if we as a society could gain some more global acceptance, we could save money and take better care of people.

Sorry for the lengthy post.


Sorry wrong title..more like why don't we let people die well?

I kinda wish this post came from a more frequent poster here.

but, i will respond, briefly:

I will concur some of my most rewarding moments in medicine have been all about end-of-life and pain control.

It is uncommonly appropriate or possible, but I still feel it is occasionally our role (when there is time) to discuss end-of-life with patients and family.

These are times when I feel like a real doctor.

HH

 

[la gringa]

agree w/ the OP and Hamhock... as much as I like procedures, I hate to do them on the wrong patient.

I think we need a new QOL index, to help guide decision making... not just use age, as leorl had mentioned. same criteria would apply to a 25 yo w/ a progressive neurologic condition s/p anoxic brain injury... sometimes we contribute to suffering more than we alleviate it, just to appease the still healthy and living. it's wrong and those are the cases that bother me 2nd most to abuse/neglect... and in a way, it IS abuse to keep someone alive for your purposes...

 

[Birdstrike]

.

 

[Cooperd0g]

Fear. People generally fear the unknown. That is why so many cling to religion - it gives them hope for something after, something better perhaps. They fear dying, fear losing their loved ones, fear being perceived as though they weren't strong enough or didn't care enough to tell you to do "everything" to keep their loved on alive.

In my experience, people who have truly lived are less afraid of death. Those who, like me, have lost many friends in their prime, seem to recognize this and try their best to actually live life. But those who have not had much of a life try and cling to it. Life is short yet so many try and extend it in unnatural ways.

The financial cost is significant. This, again, comes down to public perception. Who wants to be seen as the person who decides that "saving" another's life isn't worth the XX thousand dollars to do it, even if only for a short period of time? Few have the courage to stand there and say that in a public forum.

 

[Aesculapius]

I'm doing my ICU month right now, and it's like you read my mind. I actually had almost this exact conversation with my roommate a couple days ago.

 

[name?]

"Why don't we let people 'die well'"?

Because we know a certain percentage of people will have a family member that will come out of the woodwork afterwards and find a lawyer to sue us because they're convince their 90 year old grandmother would've had another great 3 months left if only it hadn't been for that rich greedy incompetent doctor who just didn't care.

Therefore, the default option is, and always will be, heroic measures.

I definitely get this, but I think that's where we're failing--we need to figure out how to reframe the issue so that it's no longer a potential litigation issue to provide humane and reasonable care. I had to convince a family of a man (terminal MS--quad/trached) patient who had coded at the vent facility that if he coded again I thought it was inhumane to continue efforts, and after much deliberation, they made him comfort measures.

I feel like if my perception is that the patients only experience pain--the grimace with IV/line placement/catheters etc, that maybe my defense at not going full speed ahead is that I'm violating our "do no harm" promise when we're prolonging purgatory punctuated by pain. It's not fair to leave that exclusively to family because of the associated guilt. If we could do some sort of QOL index maybe it could help take some of the emotional component out.

I only brought up the finance component because it seems insane that we do chemo on 85 year olds, or taking them to the cath lab, on the public dime, but a poor 24 year old with an appendicitis can be financially ruined by the costs. If we did less of the former, we could probably afford the latter.

Thanks for the thoughtful replies.

 

[WilcoWorld]

I am becoming increasingly more aggressive with end of life discussions. "Aggressive" may be the wrong word - perhaps I should say proactive.

Recently had a demented NH resident come in with a C2 and femur fracture sustained because she was getting out of bed without assistance because she had a UTI. When her UTI progressed to urosepsis while she was still in the ED I called the daughter and discussed our goals -"Would your mother want us to place a very large needle in her neck and start medicine to artificially increase her blood pressure?" was our question - we agreed on comfort measures. I then called our palliative care service who recommended d/c'ing fluid resuscitation and antibiotics, which I did. We then admitted the patient to the floor, rather than to the last ICU bed in the hospital. I would have never done this 4 years ago, but I really think it's the right thing to do.

I think that with the current medical climate/trajectory Palliative Care is a fellowship that EM residents should strongly consider. It's far more applicable to our daily practice than many of the more popular fellowships out there. In fact, if I could do one without moving my family I would strongly consider it.

 

[GeneralVeers]

The law has placed us in an untenable situation. We are expected to "do no harm", be an advocate for our patient, and minimize pain and suffering. That is often at odds with the fear of liability.

It is immoral that our society forces us to do things that we know are wrong.

A simple way to solve this of course would be to stop the "free healthcare" at end of life. If two doctors agree that continued heroic measures are futile and sign the affidavit, then the patient should be allowed to die. If family still wants to keep them alive they should do so at their own expense. I guarantee a lot more families would want to "pull the plug" on demented, 90 year old grandma if they are paying for it.

 

[mom2doc]

Health Care Proxies and Advance Directives...how many people on here actually have their own filled out and available? We need to be promoting them day and night. Despite the public scare tactics about disconnecting Granny, most elderly people I know want to die at home in peace and want no part of an ICU. One SICU nurse I know well used to joke that she was having DNR tattooed on her butt.

 

[WilcoWorld]

Health Care Proxies and Advance Directives...how many people on here actually have their own filled out and available? We need to be promoting them day and night. Despite the public scare tactics about disconnecting Granny, most elderly people I know want to die at home in peace and want no part of an ICU. One SICU nurse I know well used to joke that she was having DNR tattooed on her butt.

My wife & family are aware of my wishes, and I think that's more important than a piece of paper.

As for the tattoo, better to get it over your vascular access or defibrilation sites...

 

[danzman]

The law has placed us in an untenable situation. We are expected to "do no harm", be an advocate for our patient, and minimize pain and suffering. That is often at odds with the fear of liability.

It is immoral that our society forces us to do things that we know are wrong.

A simple way to solve this of course would be to stop the "free healthcare" at end of life. If two doctors agree that continued heroic measures are futile and sign the affidavit, then the patient should be allowed to die. If family still wants to keep them alive they should do so at their own expense. I guarantee a lot more families would want to "pull the plug" on demented, 90 year old grandma if they are paying for it.

Thats how it is in FL. Two docs sign off that its not worth it and the care is slowed down or stopped depending on what is going on. Works pretty good but I have seen the hospital admin get pretty scared about it.

 

[name?]

I agree with the end of life free-for-all "do everything and damn the costs!" problem. I wish it could come for a more nurturing point..."it's the right thing/ it's what they'd want if they new what all of this would feel like," (because I'm that kind of guy), but I agree that the only likely inroads to limiting that would be a financial wall.

I have had some traction with difficult cases telling patients' families that I haven't seen the patient smile, but I've heard them crying out in pain/bucking the vent etc which shows me that the dominant sensations are not nice.

It's too bad that our neurons weren't designed so that our GCS was based off of giggles/smiles instead of painful responses. That would make it way harder to not resuscitate though...patients posturing with ridiculous smiles to feet tickles would seem a little too there...but I digress.

Thanks for the great replies.

 

[Khaos]

This post was perfect timing for me. One of my patients this morning (5p to 5a shift) was an older lady in resp distress. After confirming with her 3 times that she was DNR/DNI (no paperwork), I made her comfortable with some medication and admitted her to the floor. Before she went upstairs, I was called to the room by the patient. She thanked me for everything that I had done, for honoring her wishes, and told me that I had a great future ahead of me if I treated everyone as I treated her. This reminded me of the reason I did all this. That was the reason I went into medicine. I felt that I truly helped someone tonight.

 

[leorl]

That's really nice, Khaos.

 

[JustPlainBill]

Interesting topic -- I'm an FM resident and have thought about this one a lot in my geriatric patients. I really feel like, as Americans, we've forgotten that death is a part of life. Enjoy the time you have to fullest, love completely, laugh often, don't waste time with small-minded people - you never know when your number is up....

I've tried to take this with me into practice and discuss end of life issues with every patient, certainly with every one that I admit. I'm finding that most of the elderly patients are comfortable with AND (allow natural death) and really don't want what a full code will entail....

I've found in my own life, having the AND discussion with my parents eased some of the burden of - "Is this what Mom/Dad would have wanted?" or worse "Am I killing my Mom/Dad by signing this DNR/DNI order?"......

And so it goes....

 

[beakerdan]

This is a great article by Dr. Gawande on the power of palliative care, it definitely reminds me of why I wanted to go into medicine.

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all

 

[name?]

So, to make my post all the more relevant to myself, I had two patients today that I sent home with hospice meds...neither with a clear diagnosis, but neither doing well and having comfort care wishes. And, I simultaneously admitted someone who was also not doing well, but who "wanted everything done" even though this was his 4th admission for his essentially uncorrectable problems in the last month. He probably would have benefitted the most for the morphine, but wasn't ready to stop. We have a weird job sometimes.

 

[GeneralVeers]

I've found more and more that the "end of life discussion" is being done by myself and my EM colleagues. It seems that the primary care doctors and oncologists are too afraid to address this sensitive issue head-on with patients. The worst are the stage IV cancer patients on their 10th round of chemo who come in vomiting and dehydrated. When I ask them if their oncologist has given them a prognosis, they say "no" and that they just wanted to "do more chemo".

 

[Daiphon]

This post was perfect timing for me. One of my patients this morning (5p to 5a shift) was an older lady in resp distress. After confirming with her 3 times that she was DNR/DNI (no paperwork), I made her comfortable with some medication and admitted her to the floor. Before she went upstairs, I was called to the room by the patient. She thanked me for everything that I had done, for honoring her wishes, and told me that I had a great future ahead of me if I treated everyone as I treated her. This reminded me of the reason I did all this. That was the reason I went into medicine. I felt that I truly helped someone tonight.

Keep that one in your back pocket... that's a career-affirming moment if ever I knew one. d=)

-d

 

[canadia22]

I never actually post here but I'll give this thread a try:

I suppose I get to see the worst side from the last nine months working in a large overseas ICU/Trauma unit where there is no such thing as a DNR order and legally we are required to fully resuscitate all patients. It seems no one is dying at home here and we are on many days a hospice of sorts because there are only a few here and no one can afford them . I suppose we do what we can to make patients comfortable but the ICU is no place to die and there's something a bit perverse about going full out with a patient like an eighty year old in the final stages of lung cancer and multiple pathologic fractures. Often you just watch the patient deteriorate for months in so much suffering and obvious fear – this process is so much worse with the younger patients or patients who are there due to poor care or medical error from outside.

Ours die from the same things as every other country. Of course lots of cancer, cardiovascular disease, alcoholism and trauma. But then on the other hand we see a disproportionate amount of elderly suicide attempts these days…

So I don't think there is a good death here. Patients are sedated, but almost always alone when they die. If they wake, they are almost always afraid. There are no families or religious counseling at death. I try to be as close to the patient as possible, to hold their hand or to talk to them as much as I am able. On the same note, sometimes I am afraid a little to get too involved because I get too upset about the way things are as it is.
I suppose an ER death is quicker but we have both types. Neither is easier for me.

 

[beefbroccoli]

This is a really interesting and relevant topic. I think it's important for ED docs to be adept at these types of conversations, but I also agree with the poster who said that primary care doctors and oncologists should really be providing realistic expectations for their patients. Yesterday I met a patient who was 90yo with a gazillion other comorbidities s/p Whipple surgery and now septic. I was actually rather outraged that a surgeon would consider doing a Whipple surgery on a 90 year old wtf. And that the patient's family wanted it...

And YES to having more people sign those proxies and Advanced Directives! My MICU attending jokes that not only is he DNR and DNI, he is DO NOT ICU. I think I am too.

 

[leorl]

So I had a non-verbal but pleasant gentleman and his family in the ED the other day, he broke his hip and was deemed a non-operable candidate. So instead of admitting to the hospital service, we tried to get him booked into a long-term care facility. After hours of the care coordinators sorting through the paperwork, the elderly wife gets a phone call and was really upset - apparently, the LTC place was only interested in how she was going to pay for her husband's placement, even though he has medicaid and title 19. I don't know all the details and don't understand insurance issues, but there seems to be huge barriers blocking our ability to "do the right thing." In the end after hours in the ED, we had to book him to a bed on the floor for a very expensive way to find placement.

 

[Hamhock]

So I had a non-verbal but pleasant gentleman and his family in the ED the other day, he broke his hip and was deemed a non-operable candidate. So instead of admitting to the hospital service, we tried to get him booked into a long-term care facility. After hours of the care coordinators sorting through the paperwork, the elderly wife gets a phone call and was really upset - apparently, the LTC place was only interested in how she was going to pay for her husband's placement, even though he has medicaid and title 19. I don't know all the details and don't understand insurance issues, but there seems to be huge barriers blocking our ability to "do the right thing." In the end after hours in the ED, we had to book him to a bed on the floor for a very expensive way to find placement.

I don't want to derail this otherwise excellent thread, but:

1. I didn't know there were any hip fractures that don't go to the OR (deadly if you do, deadly if you don't -- but more don't)

2. Although saving hospitalization and money is worth a good effort, I think we have to separate that from patient care/DNR/DNI/etc....that is, I think trying to save money is not what the cases above are about and I wonder if the best thing for the guy you describe is indeed hospitalization...our ability to handle an acute fracture (pain!!!) is far greater than a nursing home or such.

Just a different perspective,

HH

 

[GeneralVeers]

I don't want to derail this otherwise excellent thread, but:

1. I didn't know there were any hip fractures that don't go to the OR (deadly if you do, deadly if you don't -- but more don't)

A hip fracture is not needed to be repaired in a non-ambulatory, non-weight-bearing patient. There is no benefit to the patient of doing it, and the mortality is huge in the demented elderly with comorbid conditions.

2. Although saving hospitalization and money is worth a good effort, I think we have to separate that from patient care/DNR/DNI/etc....that is, I think trying to save money is not what the cases above are about and I wonder if the best thing for the guy you describe is indeed hospitalization...our ability to handle an acute fracture (pain!!!) is far greater than a nursing home or such.

Just a different perspective,

HH

Saving money is going to be a factor going forward (government-run healthcare) so you better get used to it. If a procedure or medicine is going to have no benefit for a patient, and costs a lot of money, then it probably shouldn't be given even if family requests it, unless they want to pay for it out of pocket.

 

[name?]

So I had a non-verbal but pleasant gentleman and his family in the ED the other day, he broke his hip and was deemed a non-operable candidate. So instead of admitting to the hospital service, we tried to get him booked into a long-term care facility. After hours of the care coordinators sorting through the paperwork, the elderly wife gets a phone call and was really upset - apparently, the LTC place was only interested in how she was going to pay for her husband's placement, even though he has medicaid and title 19. I don't know all the details and don't understand insurance issues, but there seems to be huge barriers blocking our ability to "do the right thing." In the end after hours in the ED, we had to book him to a bed on the floor for a very expensive way to find placement.

So, my understanding is probably not a whole lot better, but many(all?) situations require a 3 day hospitalization for CMS to pick up the tab for NH or SNF placement, or so I'm told by our case managers. Otherwise, families have to pay up front until the insurers start to pay (not sure when that happens).

Also, many of these places are very comfortable with pain control as they often get total knees or other post-op pts, so with proper orders, a non-ambulatory hip fx might be very appropriate at lots of these places.